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Molecular markers for drug resistant malaria represent public health tools of great but mostly unrealized potential value. A key reason for the failure of molecular resistance markers to live up to their potential is that data on the their prevalence is scattered in disparate databases with no linkage to the clinical, in vitro and pharmacokinetic data that are needed to relate the genetic data to relevant phenotypes. The ongoing replacement of older monotherapies for malaria by new, more effective combination therapies presents an opportunity to create an open access database that brings together standardized data on molecular markers of drug resistant malaria from around the world. This paper presents a rationale for creating a global database of molecular markers for drug resistant malaria and for linking it to similar databases containing results from clinical trials of drug efficacy, in vitro studies of drug susceptibility, and pharmacokinetic studies of antimalarial drugs, in a World Antimalarial Resistance Network (WARN). This database will be a global resource, guiding the selection of first line drugs for treating uncomplicated malaria, for preventing malaria in travelers and for intermittent preventive treatment of malaria in pregnant women, infants and other vulnerable groups. Perhaps most important, a global database for molecular markers of drug resistant malaria will accelerate the identification and validation of markers for resistance to artemisinin-based combination therapies and, thereby, potentially prolong the useful therapeutic lives of these important new drugs.
This article is the result of a workshop held in October, 2006, at the Wellcome Trust Sanger Genome Centre in Hinxton, England. The background section reviews lessons learned over the last 15 years as molecular markers for drug resistant malaria were identified, validated, and to a regrettably limited degree, applied as tools to guide the use of drugs whose efficacy is now severely compromised by resistance. An argument is made that this history must not be repeated in the era of artemisinin-based combination therapies (ACTs) by using molecular markers only to chart passively the rise of resistance to this new generation of highly efficacious drugs. A rationale is provided for creating a global database for molecular markers of drug resistant malaria that will be linked to databases for malaria drug efficacy trials, in vitro drug resistance, and pharmacokinetics, and for using this network of databases (World Antimalarial Resistance Network, or WARN) proactively as a tool to monitor and deter resistance and to guide malaria treatment and prevention policies. Potential sources of data that would go into the database are described, followed by discussion of who will benefit from the creation of a tool for monitoring antimalarial drug resistance and facilitating rapid public health responses to changes in resistance profiles.
Molecular markers for drug resistant malaria are based on genetic changes that confer parasite resistance to drugs used to treat and prevent malaria. Polymorphisms in the Plasmodium falciparum chloroquine resistance transporter (PfCRT) confer resistance to chloroquine [1,2], and mutations in the P-glycoprotein homologue (Pgh1) encoded by pfmdr1 modulate this resistance [3]. Polymorphisms in pfmdr1 and amplifications of this gene also affect susceptibility to structurally unrelated antimalarial drugs, including mefloquine, artesunate, lumefantrine and quinine [4-6]. Polymorphisms in P. falciparum dihydrofolate reductase (DHFR) cause resistance to the antifolate drugs including pyrimethamine and other DHFR inhibitors, and polymorphisms in dihydropteroate synthase (DHPS) cause resistance to sulphadoxine and other sulphas and sulphones [7,8].
These molecular markers have been validated as tools for surveillance of resistance [9,10], and their potential value to policymakers has been demonstrated by their use to help control a malaria epidemic [11], to guide national malaria treatment policies [12] and to monitor changes in parasite drug susceptibility following changes in malaria drug treatment policy [13]. However, by the time the molecular markers for resistance to chloroquine and the antifolate combination sulphadoxine-pyrimethamine (SP) were established as tools for predicting clinical treatment outcomes, resistance had already severely compromised the efficacy of these drugs in most of the world. The emergence and spread of resistance to chloroquine and SP has led to recommendations that they be replaced with ACTs, which offer much-improved efficacy [14]. However, the development of resistance to artemisinins or their partner drugs may severely limit the utility of ACTs, and reliable markers for monitoring resistance to ACTs are needed.
Development and validation of molecular markers
Candidate molecular markers for resistance to chloroquine, SP and mefloquine were identified by laborious molecular genetic approaches, including identifying parasite homologues of genes that mediate resistance in other organisms [8,15,16], and analysing the progeny of genetic crosses between sensitive and resistant parasites [1,7,17]. Differences in DNA sequence or gene expression between sensitive and resistant parasites were described, and point mutations, [1,7,18] and differences in gene expression or copy number [19,20] were evaluated for associations with in vitro resistance phenotypes. Causal relationships between molecular markers and in vitro resistance were then confirmed in genetic transformation studies in which DNA sequence substitutions conferred changes in the resistance phenotypes of cultured parasite clones [2,21];Triglia, 1998 596/id;Reed, 2000 1279/id} or in model systems such as yeast [22,23].
To assess their clinical importance, molecular markers were evaluated in the field in ecological studies [24,25] and clinical trials [9,10,26]. Establishing the predictive value of molecular markers for outcomes of antimalarial drug treatment has been challenging, mainly because factors other than intrinsic parasite resistance affect these outcomes. Even for markers that correlate almost perfectly with in vitro resistance, other factors including acquired immunity [9,27], initial parasite biomass, compliance, dosing [28] and pharmacokinetics [20,29] affect the clearance of drug-resistant parasites. As the prevalence of resistance markers approaches fixation in a population, these non-resistance factors become more important in determining treatment outcomes [30]. The most important contributor to clearance of resistant parasites in high transmission areas is acquired immunity, which can be partially accounted for by controlling for age in a simple model for relating the prevalence of molecular markers to treatment failure rates [10,31]. When validated in a variety of settings with different levels of malaria transmission and acquired immunity and where resistance markers are not yet fixed in the population, this "genotype-failure index" model allows good prediction of treatment efficacy based on the prevalence of molecular markers for resistance (Figure 1). Unfortunately, without available pooled data from diverse sites, such as a global database for molecular markers would provide, this model has been validated only in a few local settings, including Mali [10], Uganda [32] and Tanzania [12] (Figure 1). Multivariate models that account for pharmacokinetic and other factors that contribute to treatment outcomes would improve the predictive ability of molecular markers for resistance, providing strong justification for the set of linked databases proposed in this series of papers. Such a comprehensive global database would provide the statistical power needed to assess the roles played by multiple genetic and non-genetic determinants of treatment outcomes.
Figure 1. Prevalence of sulphadoxine-pyrimethamine (SP) treatment failure and molecular markers of resistance to SP at five sites in Tanzania. Ratios of prevalence of the DHFR triple mutant to SP treatment failure ranged from 2.0 to 2.1 at four of the five sites where SP resistance was low or moderate, suggesting that this molecular marker could serve as a reliable surrogate for SP efficacy at these sites. Adapted from [12] with permission.
Reliable methods for using molecular markers to monitor chloroquine and SP resistance were established only after resistance to these drugs was so widespread that the information provided by molecular surveys was, with some notable exceptions [11,12], mainly of historical interest and of little immediate relevance to antimalarial treatment policies. As ACTs become the first line in most countries, it will be important to characterize markers for resistance as it develops, before clinical efficacy is lost. Most efforts to date to identify the genetic determinants of resistance to the drugs that comprise ACTs have taken a candidate gene approach, based on homologues of resistance genes from other organisms or suspected targets for drug action. In an example of this approach, in vitro and clinical evidence suggests that increased pfmdr1 copy number is associated with decreased sensitivity to artemisinin and other antimalarial drugs [5,20]. Genes encoding potential targets of artemisinin action are also being pursued as molecular markers. Based on studies showing that artemisinins inhibit a Ca++ ATPase, sequence changes in the gene encoding PfATPAse6 were assayed and found to be associated with in vitro resistance in isolates from South America, but not Africa or Asia [33]. These candidate gene approaches rely on an optimistic hope that individual genes will be found to be responsible for resistance to ACTs. In the more likely scenario in which resistance to these drugs is mediated by multiple genes, whole-genome strategies that search for signatures of selection around resistance loci may accelerate the identification of molecular markers for resistance [34-36].
Rationale for a global database of resistance markers
Clinical trials are and will remain the gold standard for measuring drug efficacy, but when assays for molecular resistance markers are sufficiently predictive of clinical treatment outcomes, their simplicity, robustness and scalability make them a potentially powerful adjunct to clinical trials. Molecular assays for common polymorphisms are straightforward and relatively low cost when scaled up. The assays generally evaluate DNA, so they can be performed from blood spots on filter paper, which are easy to collect and store [37]. Thus, samples can easily be collected by health workers when patients present for diagnosis and treatment of malaria, or in targeted cross-sectional surveys in areas with high prevalence of asymptomatic malaria infection. These molecular analyses are routinely performed in many laboratories in endemic countries and can be shipped internationally for quality control without a need for special containers or precautions.
How resistance markers have been used
The potential public health value of molecular resistance markers lies in their utility as tools for surveillance of trends in parasite drug sensitivity. Routine use of molecular data in decisions regarding appropriate antimalarial therapy is not yet a reality, in part because of the lack of mechanisms for timely sharing of molecular data in formats that are useful for non-specialists. However, the direct practical value of molecular surveys was demonstrated in 1999 in Mali, where chloroquine was then the first line antimalarial treatment [11]. A sharp increase in the incidence of malaria in a non-immune population occurred in a district in northern Mali where clinical assessments of drug efficacy could not be made because of limited infrastructure and civil unrest. An epidemic outbreak investigation team collected slides for microscopic diagnosis and filter paper blood samples for molecular analyses. In the capital city, Bamako, microscopy and molecular assays for markers predictive of resistance to chloroquine and SP suggested an unexpectedly high prevalence of resistance to chloroquine, but not to SP. Based on this information, special efforts were made to obtain SP and the population was effectively treated. Had evaluation of the gene-specific molecular markers not been performed, chloroquine would have been used to try to contain the epidemic and considerable malaria morbidity and mortality would have been anticipated.
In another example of molecular markers informing treatment policy, when a replacement for chloroquine was urgently needed in Tanzania, the prevalence of SP resistance markers predicted that, while SP would initially be more effective than chloroquine, its efficacy would soon be compromised. Based on this information, the Ministry of Health adopted SP on an interim basis as the best available first line drug, while actively seeking a more effective regimen [12]. Molecular markers for resistance are also guiding malaria treatment policy in Southeast Asia, where initial reports of high rates of artesunate-mefloquine treatment failure on the Thai-Cambodian border [38,39] were met with skepticism about whether they represented resistance. However, when these treatment failures were shown to be highly correlated with pfmdr1 copy number [40], suggesting bona fide resistance to mefloquine, health officials began conducting surveys for the prevalence of this molecular marker and using this information to guide the choice of sites for in vivo assessments of efficacy.
Studies in Malawi illustrate the power of molecular resistance markers to track changes in drug susceptibility following changes in drug use policies. In 1993, Malawi became the first African nation to replace chloroquine with SP as the first line antimalarial drug countrywide [41]. Molecular surveillance of the PfCRT, DHFR and DHPS markers demonstrated two clear trends. First, the prevalence of the PfCRT T76 allele, which is associated with chloroquine resistance, declined rapidly after the withdrawal of chloroquine, from 85% in 1992 to undetectable levels by 2001. Second, the prevalence of parasites that carried DHFR mutations associated with resistance to SP progressively increased [1] (Figure 2). A clinical trial recently confirmed that these changes in the prevalence of resistance-mediating mutations have been accompanied by a dramatic increase in chloroquine efficacy in Malawi for the treatment of malaria, from about 50% to 99% in just 12 years, and an equally dramatic decrease in SP efficacy, from nearly 100% to 21% during the same time period [42].
Figure 2. Prevalence of drug-resistance mutations in Plasmodium falciparum malaria infections in Malawi before and after chloroquine was replaced with sulphadoxine-pyrimethamine in 1993. Chloroquine resistance-conferring T76 mutation in PfCRT (A); Pyrimethamine resistance-conferring C59R mutations in DHFR (B); Adapted from [13] with permission.
Why markers for chloroquine and SP resistance are still useful
Today, although the efficacies of chloroquine and SP have declined to unacceptable levels in much of Africa, attention to parasite mutations that mediate resistance to these drugs remains relevant for several reasons. First, in some areas the older drugs remain efficacious, including SP in parts of West Africa, and the combination of amodiaquine and SP in many areas [43,44]. Because they are inexpensive (about $0.20 U.S. per treatment), safe, and given in simple one- or three-day regimens, these drugs are likely to continue to be used even in the face of expert consensus that ACTs should be the first line therapy. However, little support will be available for continued clinical trials of chloroquine or SP efficacy under programmes funded by donors who recommend exclusive use of ACTs. Molecular surveillance that shows increasing prevalence of resistance markers known to be associated with treatment failure may be the only evidence available to convince policymakers that it is time to stop using these older drugs as their efficacy declines.
Second, SP is now recommended and increasingly used as intermittent preventive therapy (IPT) to prevent malaria in pregnant women [45] and infants [46], even in areas where SP efficacy for treatment of acute malaria is compromised. The value of mutations in DHFR and DHPS for predicting efficacy of IPT with SP needs to be established in settings with different levels of malaria transmission and acquired immunity, because of the impact of these factors on the relationship between prevalence of molecular markers and clinical efficacy. A global database of molecular markers for resistance will aid and accelerate the process of validating simple models for using these markers to predict SP efficacy for IPT, and then provide a means for monitoring this efficacy to guide decisions to move to newer but more expensive drugs as these are brought on line.
Third, an antifolate drug that is closely related to SP, trimethoprim-sulphamethoxazole, is a standard treatment for children with fever attributable to either respiratory infections or malaria [47], and is recommended as prophylaxis to prevent opportunistic infections in HIV-infected individuals in developing countries [48]. Trimethoprim-sulphamethoxazole prophylaxis effectively prevents malaria [49], and has the same genetic basis of in vitro resistance as SP [50,51]. However, it has been difficult to discern the impact that the DHFR and DHPS mutations that mediate resistance to SP may have on the protective efficacy of trimethoprim-sulphamethoxazole [49,52]. Surveillance for these mutations and pooled analysis of data from genotype and efficacy studies will clarify these associations. With a better understanding of relevant associations, coordinated surveillance for DHFR and DHPS mutations will be very helpful in determining optimal management strategies for people living with HIV in malaria endemic regions [53].
The fourth and final reason for continued surveillance of markers for resistance to chloroquine and SP is that, as was recently demonstrated in Malawi, the withdrawal of antimalarial drugs from use in a region may be followed by a return of clinical efficacy, heralded by falling prevalence of molecular markers for resistance [13,42]. Thus, surveillance of markers of resistance may help to guide the reintroduction of drugs whose efficacy has returned, in new combinations designed to deter the reemergence of resistance, thus creating the possibility of rotating drugs to maintain their efficacy [54].
Molecular markers in the ACT era
As malaria treatment moves into the era of ACTs, the most important rationale for a database of molecular markers of drug resistance will be surveillance for resistance to the drugs included in these combinations. ACTs were designed to deter resistance by attacking parasites simultaneously with two or more drugs with different mechanisms of action, reducing the probability of resistance emerging [14]. These drug combinations were developed in settings of low malaria transmission, where the pharmacokinetic mismatch between the short-acting artemisinins and longer-acting partner drugs was not problematic, due to the low risk of encountering new infections during the elimination phase of the longer-acting partner drug. As these drugs are deployed in Africa, where the risk of new infection soon after treatment is high, the ability of the artemisinins to protect partner drugs from resistance is diminished. Thus, as ACTs are rolled out as first-line therapies for malaria, surveillance of molecular markers should be used to monitor the development of resistance to ACT partner drugs.
Each ACT partner drug is likely to select for resistance, potentially leading to loss of treatment efficacy as well as failure to protect the artemisinins against the development of resistance. At present the most important partner drugs used with artemisinins in ACTs are amodiaquine, lumefantrine, and piperaquine. The molecular mediators of resistance are not as well defined for these drugs as they are for chloroquine and SP, but recent data show hints of mechanisms of resistance. For amodiaquine, polymorphisms in both PfCRT and Pgh1 appear to predict resistance and to be selected for by treatment with amodiaquine [55] or artesunate-amodiaquine [56]. Artemether-lumefantrine treatment selects for polymorphisms in pfmdr1 associated with diminished sensitivity to the related drug halofantrine [57,58]. Markers for piperaquine resistance have not been identified, but this aminoquinoline may well act similarly to chloroquine and amodiaquine in its selection of resistance-mediating mutations.
To avoid unacceptably long delays in identifying, validating and deploying molecular markers of ACT resistance, the malaria research and control community must be prepared to investigate aggressively early reports of resistance, confirm resistance with careful in vitro assays, and bring genetic and genomic tools to bear to elucidate mechanisms and identify candidate molecular markers. The sequencing of the P. falciparum genome has led to genome-wide approaches that may help to identify genetic markers of drug resistance far more quickly than was previously possible [35,59,60]. There is a critical need to detect and confirm resistance to the component drugs in ACTs, and to the artemisinins in particular, as soon as it emerges, and then to develop and validate tools to monitor this resistance. These tools can then be applied in real time to help establish rational treatment policies and to design and deploy drug combinations that will deter resistance. The creation of a global database of molecular markers for drug resistance is a critical step in this process.
To the extent that known markers for resistance to ACT partner drugs are available now, a global database for collating and analysing trends in their prevalence will inform choices of which ACTs to introduce as countries change their policies. Moreover, a database of the type proposed will accelerate the process of validating predictive genotype-failure index models for ACT partner drugs in different settings with varying levels of malaria transmission and acquired immunity. Even more important, without a global database of molecular markers for drug resistant malaria, the evaluation of candidate molecular markers for resistance to the artemisinins and their partner drugs and the discovery of new such markers through whole-genome analyses is certain to lag far behind the development of resistance to these drugs.
Sources of data
Drug efficacy trials
The data included in a global database of molecular markers for drug resistant malaria will consist primarily of the results of molecular assays for resistance markers. These will come from several sources. First, in most clinical trials of antimalarial drug efficacy, filter paper blood samples are routinely collected to preserve parasite DNA at the time of treatment and whenever post-treatment infections appear. These samples are usually subjected to analysis for genetic markers to determine whether post-treatment infections are due to recrudescence or to new infections, and in many cases the samples are also analysed for the presence of resistance markers. In studies aimed at validating candidate markers for resistance, these samples can be used to ask two types of questions: (1) Are resistance markers more common in post-treatment infections than in the initial infections, i.e. does drug treatment select for specific markers? (2) Is the presence of molecular markers for resistance at the time of presentation with malaria associated with the clinical and parasitological outcome of drug treatment, i.e. can markers predict efficacy? The first question is an important step in assessing putative markers for biological evidence of their association with resistance in vivo. The second question is a key step in validating the utility of molecular markers for predicting clinically relevant outcomes.
Molecular surveillance
In addition to surveys and efficacy trials in endemic areas, travelers returning from these areas to developed countries can provide surveillance data on drug resistant malaria [61,62]. Data from this source would provide useful information for travel medicine specialists and also serve as a sentinel surveillance system to direct targeted investigation of resistance [63]. Genotyping of isolates also subjected to in vitro drug susceptibility testing will provide another source of valuable data. These in vitro genotype-phenotype studies will be a crucial component of investigations to confirm and characterize reports of clinical resistance to ACTs, because they assess intrinsic drug resistance in the absence of confounding clinical factors such as host immunity. Lastly, data will come from the use of molecular markers as a broad surveillance tool. Once the association between resistance markers and clinical outcomes is well established, evaluation of samples collected in simple community surveys and at points of malaria diagnosis can provide a "snapshot" of local resistance patterns.
The need for standardization and linkage
Although standardized methods for recording and interpreting molecular resistance results have been proposed [26], a wide variety of approaches is presently used to analyse, interpret and report these data. Making the ability to access large datasets contingent on contributing data that adhere to standard formats will provide a strong incentive for investigators to do so, and should vastly increase the value of the large volumes of data that are presently available, but unlinked. For data from any of these sources, it will be essential to build systems that link the molecular data to corresponding demographic, geographic, epidemiological, clinical, in vitro and pharmacokinetic data. To insure that data are comparable and interpretable, it will be important to standardize genotyping technologies as well as data analysis and reporting. To this end reference laboratories should be supported to maintain and update standardized protocols on the network, and to provide blinded quality assurance testing of samples sent by contributing groups. Standardized reagents and controls can be provided by centralized references centers [64] or regional reference laboratories.
Resistant vivax malaria
Chloroquine resistant Plasmodium vivax arose in Asia in the 1980s [65] and has since spread throughout significant parts of Asia and South America. Resistance to other drugs, including antifolates and primaquine, also occurs with P. vivax. Some progress has been made toward identifying molecular markers for drug resistant vivax malaria [66,67]. As this work progresses, a database for molecular markers of resistance could easily be adapted to incorporate data for P. vivax, and inclusion of these data would aid in the process of validating P. vivax resistance markers.
Existing datasets
A starting point for a new global database will be to link a number of valuable existing databases. The utility of this approach will be limited to those datasets that include individual treatment outcome data that are amenable to conversion to standardized formats. The East African Network for Monitoring Antimalarial Treatment (EANMAT), formed in 1997, was the first network for monitoring drug resistance in Africa, with the objective of providing a dynamic assessment of current antimalarial treatment using standardized protocols, and generating data to guide policy changes. Similar regional surveillance networks have been created linking neighboring countries in other regions of Africa and in Southeast Asia and South America. The Multilateral Initiative on Malaria initiated an Antimalarial Drug Resistance Network linking fives study sites in Africa with the plan to systematically assess specific gene mutations, in vitro drug susceptibility, drug pharmacokinetics, and clinical treatment responses. The Mapping Malaria Risk in Africa project [68] has also developed a drug resistance database, sourcing published and unpublished in vivo and molecular resistance data from as many sites in Africa as possible. A global database would have the potential to link many of these existing databases, and greatly increasing both their usefulness and their use.
Who will benefit?
A variety of consumers from different sectors will use and benefit from this database. Policymakers in malaria-endemic countries represent a primary set of clients. As local authorities attempt to promote evidence-based management of malaria, high quality up-to-date data on drug efficacy are needed. Of greatest value will be results of controlled clinical trials of antimalarial drug efficacy. However, limited resources will not support the number of trials needed to provide comprehensive characterization of efficacy, forcing authorities to make country-wide policies based on data from a limited number of sites. Well-designed studies of molecular markers of drug resistance can help to fill this gap. A database rapidly cataloguing molecular data and relaying it to policymakers would greatly facilitate the use of these data to help guide malaria treatment policies. It will be important for the data to be presented in ways that are easy for those with a range of expertise to understand and use. The database will facilitate this process by providing a means for standardizing data analysis, interpretation and reporting. The regional surveillance groups described in the preceding section will be a second set of consumers who benefit from the database. A new database linking and strengthening these networks will facilitate efficient use of available molecular data and stimulate trans-region discussions to encourage rational treatment policies. Those advising travelers from malaria-free countries to endemic areas will benefit from a public access database that provides early signals of resistance. Finally, the malaria research community will also profit from a global database. Research to understand the roles of known polymorphisms in resistance, and most importantly to identify new mediators of resistance, will be greatly helped by the availability of data describing prevalences of markers of resistance and associations with treatment outcomes. The database would include portals for data entry and analysis, with gates controlled by contributors who could decide when to submit data to the central database and when to make it accessible to all users. Working out the information technology and intellectual property issues for such a database will be challenging, but not without precedent, and will benefit from advances in systems for data management and the non-commercial nature of almost all malaria research programs.
Molecular markers for resistance to older malaria drugs were validated only after the efficacy of these drugs was severely compromised by resistance. The potential of these markers as tools for malaria control has not been fully realized, in large part because data on their prevalence is scattered in many published and unpublished datasets in non-standardized formats. The development and validation of molecular markers for new combination antimalarial therapies is a high priority. In this paper a case has been made for creating a global public access database for molecular markers of drug resistance, linked to similar databases containing data on clinical efficacy, in vitro susceptibility and pharmacokinetics of antimalarial drugs, together comprising a World Antimalarial Resistance Network. This database would accelerate the development of markers for resistance to artemisinin-based and other combination therapies and help to inform rational malaria treatment and prevention policies designed to prevent and contain drug resistant malaria.
ACT, artemisinin-based combination therapy
DHFR, dihydrofolate reductase
DHPS, dihydropteroate synthase
PfCRT, Plasmodium falciparum chloroquine resistance transporter
Pgh1, P-glycoprotein-1
SP, sulphadoxine-pyrimethamine
WARN, World Antimalarial Resistance Network
Authors' contributions
All authors contributed to the discussions that gave rise to the manuscript. CVP and PJR wrote the first draft and edited the final manuscript. CR edited the manuscript which includes contributions from JWB, CTH, HHJ, WM, SRM, KM, IN, RNP, RWS, CHS, CJS and PAZ.
The meeting that gave rise to this paper was funded by a grant from the Bill and Melinda Gates Foundation.
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White NJ: Why is it that antimalarial drug treatments do not always work?
Annals of Tropical Medicine & Parasitology 1998, 92:449-458. Publisher Full Text
Dzinjalamala FK, Macheso A, Kublin JG, Taylor TE, Barnes KI, Molyneux ME, et al.: Blood folate concentrations and in vivo sulfadoxine-pyrimethamine failure in Malawian children with uncomplicated Plasmodium falciparum malaria.
Am J Trop Med Hyg 2005, 72:267-272. PubMed Abstract | Publisher Full Text
Francis D, Nsobya SL, Talisuna A, Yeka A, Kamya MR, Machekano R, et al.: Geographic differences in antimalarial drug efficacy in Uganda are explained by differences in endemicity and not by known molecular markers of drug resistance.
J Infect Dis 2006, 193:978-986. PubMed Abstract | Publisher Full Text
Tinto H, Sanou B, Dujardin JC, Ouedraogo JB, VAN OC, Erhart A, et al.: Usefulness of the Plasmodium falciparum chloroquine resistance transporter T76 genotype failure index for the estimation of in vivo chloroquine resistance in Burkina Faso.
Am J Trop Med Hyg 2005, 73:171-173. PubMed Abstract | Publisher Full Text
Kyabayinze D, Cattamanchi A, Kamya MR, Rosenthal PJ, Dorsey G: Validation of a simplified method for using molecular markers to predict sulfadoxine-pyrimethamine treatment failure in African children with falciparum malaria.
Am J Trop Med Hyg 2003, 69:247-252. PubMed Abstract | Publisher Full Text
Jambou R, Legrand E, Niang M, Khim N, Lim P, Volney B, et al.: Resistance of Plasmodium falciparum field isolates to in-vitro artemether and point mutations of the SERCA-type PfATPase6.
Lancet 2005, 366:1960-1963. PubMed Abstract | Publisher Full Text
Mu J, Ferdig MT, Feng X, Joy DA, Duan J, Furuya T, et al.: Multiple transporters associated with malaria parasite responses to chloroquine and quinine.
Mol Microbiol 2003, 49:977-989. PubMed Abstract | Publisher Full Text
Volkman SK, Sabeti PC, Decaprio D, Neafsey DE, Schaffner SF, Milner DA Jr, et al.: A genome-wide map of diversity in Plasmodium falciparum.
Nat Genet 2007, 39:113-119. PubMed Abstract | Publisher Full Text
Jeffares DC, Pain A, Berry A, Cox AV, Stalker J, Ingle CE, et al.: Genome variation and evolution of the malaria parasite Plasmodium falciparum.
Nat Genet 2007, 39:120-125. PubMed Abstract | Publisher Full Text
Plowe CV, Djimde A, Bouare M, Doumbo O, Wellems TE: Pyrimethamine and proguanil resistance-conferring mutations in Plasmodium falciparum dihydrofolate reductase: polymerase chain reaction methods for surveillance in Africa.
Am J Trop Med Hyg 1995, 52:565-568. PubMed Abstract | Publisher Full Text
Rojanawatsirivej C, Vijaykadga S, Amklad I, Wilairatna P, Looareesuwan S: Monitoring the therapeutic efficacy of antimalarials against uncomplicated falciparum malaria in Thailand.
Southeast Asian J Trop Med Public Health 2003, 34:536-541. PubMed Abstract
Denis MB, Tsuyuoka R, Lim P, Lindegardh N, Yi P, Top SN, et al.: Efficacy of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria in northwest Cambodia.
Trop Med Int Health 2006, 11:1800-1807. PubMed Abstract | Publisher Full Text
Alker AP, Lim P, Sem R, Shah NK, Yi P, Bouth DM, et al.: Pfmdr1 and in vivo resistance to artesunate-mefloquine in Falciparum malaria on the Cambodian-Thai border.
Am J Trop Med Hyg 2007, 76:641-647. PubMed Abstract | Publisher Full Text
Bloland PB, Lackritz EM, Kazembe PN, Were JB, Steketee R, Campbell CC: Beyond chloroquine: implications of drug resistance for evaluating malaria therapy efficacy and treatment policy in Africa.
J Infect Dis 1993, 167:932-937. PubMed Abstract
Laufer MK, Thesing PC, Eddington ND, Masonga R, Dzinjalamala FK, Takala SL, et al.: Return of chloroquine antimalarial efficacy in Malawi.
N Engl J Med 2006, 355:1959-1966. PubMed Abstract | Publisher Full Text
Dorsey G, Njama D, Kamya MR, Cattamanchi A, Kyabayinze D, Staedke SG, et al.: Sulfadoxine/pyrimethamine alone or with amodiaquine or artesunate for treatment of uncomplicated malaria: a longitudinal randomised trial.
Lancet 2002, 360:2031-2038. PubMed Abstract | Publisher Full Text
Zongo I, Dorsey G, Rouamba N, Tinto H, Dokomajilar C, Guiguemde RT, et al.: Artemether-lumefantrine versus amodiaquine plus sulfadoxine-pyrimethamine for uncomplicated falciparum malaria in Burkina Faso: a randomised non-inferiority trial.
Lancet 2007, 369:491-498. PubMed Abstract | Publisher Full Text
Rogerson SJ, Chaluluka E, Kanjala M, Mkundika P, Mhango C, Molyneux ME: Intermittent sulfadoxine-pyrimethamine in pregnancy: effectiveness against malaria morbidity in Blantyre, Malawi, in 1997–99.
Trans R Soc Trop Med Hyg 2000, 94:549-553. PubMed Abstract | Publisher Full Text
Schellenberg D, Menendez C, Kahigwa E, Aponte J, Vidal J, Tanner M, et al.: Intermittent treatment for malaria and anaemia control at time of routine vaccinations in Tanzanian infants: a randomised, placebo-controlled trial.
Lancet 2001, 357:1471-1477. PubMed Abstract | Publisher Full Text
Hamel MJ, Holtz T, Mkandala C, Kaimila N, Chizani N, Bloland P, et al.: Efficacy of trimethoprim-sulfamethoxazole compared with sulfadoxine-pyrimethamine plus erythromycin for the treatment of uncomplicated malaria in children with integrated management of childhood illness dual classifications of malaria and pneumonia.
Am J Trop Med Hyg 2005, 73:609-615. PubMed Abstract | Publisher Full Text
Mermin J, Bunnell R, Lule J, Opio A, Gibbons A, Dybul M, et al.: Developing an evidence-based, preventive care package for persons with HIV in Africa.
Trop Med Int Health 2005, 10:961-970. PubMed Abstract | Publisher Full Text
Thera MA, Sehdev PS, Coulibaly D, Traore K, Garba MN, Cissoko Y, et al.: Impact of trimethoprim-sulfamethoxazole prophylaxis on falciparum malaria infection and disease.
J Infect Dis 2005, 192:1823-1829. PubMed Abstract | Publisher Full Text
Iyer JK, Milhous WK, Cortese JF, Kublin JG, Plowe CV: Plasmodium falciparum cross-resistance between trimethoprim and pyrimethamine.
Lancet 2001, 358:1066-1067. PubMed Abstract | Publisher Full Text
Triglia T, Wang P, Sims PF, Hyde JE, Cowman AF: Allelic exchange at the endogenous genomic locus in Plasmodium falciparum proves the role of dihydropteroate synthase in sulfadoxine-resistant malaria.
EMBO J 1998, 17:3807-3815. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Malamba SS, Mermin J, Reingold A, Lule JR, Downing R, Ransom R, et al.: Effect of cotrimoxazole prophylaxis taken by human immunodeficiency virus (HIV)-infected persons on the selection of sulfadoxine-pyrimethamine-resistant malaria parasites among HIV-uninfected household members.
Am J Trop Med Hyg 2006, 75:375-380. PubMed Abstract | Publisher Full Text
Laufer MK, Plowe CV: Cotrimoxazole prophylaxis and malaria in Africa: Have the important questions been answered?
Am J Trop Med Hyg 2006, 75:373-374. PubMed Abstract | Publisher Full Text
Laufer MK, Plowe CV: Withdrawing antimalarial drugs: impact on parasite resistance and implications for malaria treatment policies.
Drug Resist Updat 2004, 7:279-288. PubMed Abstract | Publisher Full Text
Dokomajilar C, Lankoande ZM, Dorsey G, Zongo I, Ouedraogo JB, Rosenthal PJ: Roles of specific Plasmodium falciparum mutations in resistance to amodiaquine and sulfadoxine-pyrimethamine in Burkina Faso.
Am J Trop Med Hyg 2006, 75:162-165. PubMed Abstract | Publisher Full Text
Humphreys GS, Merinopoulos I, Ahmed J, Whitty CJ, Mutabingwa TK, Sutherland CJ, et al.: Amodiaquine and artemether-lumefantrine select distinct alleles of the P. falciparum pfmdr1 gene in Tanzanian children treated for uncomplicated malaria.
Antimicrob Agents Chemother 2006. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Sisowath C, Stromberg J, Martensson A, Msellem M, Obondo C, Bjorkman A, et al.: In vivo selection of Plasmodium falciparum pfmdr1 86N coding alleles by artemether-lumefantrine (Coartem).
J Infect Dis 2005, 191:1014-1017. PubMed Abstract | Publisher Full Text
Dokomajilar C, Nsobya SL, Greenhouse B, Rosenthal PJ, Dorsey G: Selection of Plasmodium falciparum pfmdr1 alleles following therapy with artemether-lumefantrine in an area of Uganda where malaria is highly endemic.
Antimicrob Agents Chemother 2006, 50:1893-1895. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Ferdig MT, Cooper RA, Mu J, Deng B, Joy DA, Su XZ, et al.: Dissecting the loci of low-level quinine resistance in malaria parasites.
Mol Microbiol 2004, 52:985-997. PubMed Abstract | Publisher Full Text
Mu J, Awadalla P, Duan J, McGee KM, Keebler J, Seydel K, et al.: Genome-wide variation and identification of vaccine targets in the Plasmodium falciparum genome.
Nat Genet 2007, 39:126-130. PubMed Abstract | Publisher Full Text
Jelinek T, Peyerl-Hoffmann G, Muhlberger N, Wichmann O, Wilhelm M, Schmider N, et al.: Molecular surveillance of drug resistance through imported isolates of Plasmodium falciparum in Europe.
Malar J 2002, 1:11. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text
Labbe AC, Patel S, Crandall I, Kain KC: A molecular surveillance system for global patterns of drug resistance in imported malaria.
Emerg Infect Dis 2003, 9:33-36. PubMed Abstract | Publisher Full Text
Schwartz E, Bujanover S, Kain KC: Genetic confirmation of atovaquone-proguanil-resistant Plasmodium falciparum malaria acquired by a nonimmune traveler to East Africa.
Clin Infect Dis 2003, 37:450-451. PubMed Abstract | Publisher Full Text
Wu Y, Fairfield AS, Oduola A, Cypess RH: The Malaria Research and Reference Reagent Resource (MR4) Center – creating African opportunities.
Afr J Med Med Sci 2001, 30(Suppl):52-54. PubMed Abstract
Baird JK, Basri H, Purnomo , Bangs MJ, Subianto B, Patchen LC, et al.: Resistance to chloroquine by Plasmodium vivax in Irian Jaya, Indonesia.
Am J Trop Med Hyg 1991, 44:547-552. PubMed Abstract | Publisher Full Text
Eldin de Pecoulas P, Tahar R, Ouatas T, Mazabraud A, Basco LK: Sequence variations in the Plasmodium vivax dihydrofolate reductase-thymidylate synthase gene and their relationship with pyrimethamine resistance.
Mol Biochem Parasitol 1998, 92:265-273. PubMed Abstract | Publisher Full Text
Auliff A, Wilson DW, Russell B, Gao Q, Chen N, Anh lN, et al.: Amino acid mutations in Plasmodium vivax DHFR and DHPS from several geographical regions and susceptibility to antifolate drugs.
Am J Trop Med Hyg 2006, 75:617-621. PubMed Abstract | Publisher Full Text
Mapping Malaria Risk in Africa [http://www.mara.org.za] webcite


text:
We've been looking over the May 2011 releases and deciding what books we're all longing to try. In going over this month's rather lengthy list of anticipated reads from everyone here at AAR, I saw two books mentioned again and again – one contemporary and one historical. Eight of us can't wait to get our eager paws on Rachel Gibson's latest, Any Man of Mine, and Dangerous in Diamonds by Madeline Hunter is not far behind with seven votes from reviewers who want Castleford's story. So, what are you eagerly awaiting this May?
Title and Author | Reviewer | |
Any Man of Mine by Rachel Gibson | Sandy, Maggie, Dabney, Heather S., Jane, Lea, LinnieGayl, Leigh | |
Dangerous in Diamonds by Madeline Hunter | Jean, Heather S.,Nanette, Dabney, Lee, Leigh | |
Follow My Lead by Kate Noble | Blythe,Jane,Lee, Jean | |
Cowboy, Take Me Away by Kathleen Eagle | Pat, Lynn | |
Eleven Scandals to Start to Win a Duke's Heart by Sarah MacLean | Nanette,Lee | |
Breaking Point by Pamela Clare | Heather B., Jacqueline | |
A Tapestry of Dreams (reissue) by Roberta Gellis | Lynn, Rike | |
One Magic Moment by Lynn Kurland | Pat, Lee | |
The Vampire Dimitri by Colleen Gleason | Lynn | |
Queen by Right by Anne Easter Smith | Nanette | |
Just Surrender by Kathleen O'Reilly | Dabney | |
Jace by Sarah McCarty | Heather B. | |
Nowhere Near Respectable by Mary Jop Putney | Jane | |
Portrait of Seduction by Carrie Lofty | Lynn | |
Comanche Magic by Catherine Anderson | Pat | |
The Prodigal Son by Beth Andrews | Rike | |
Warcry by Elizabeth Vaughan | Jean | |
Klondike Medicine Woman by Linda Ford | Pat | |
Midnight's Wild Passion by Anna Campbell | Lea | |
Face of Danger by Roxanne St. Clare | Rike |

subset: commoncrawl


text:
Cryptopotamon (Cryptopotamon anacoluthon)
Kingdom | Animalia |
Phylum | Arthropoda |
Class | Crustacea |
Order | Decapoda |
Family | Potamidae |
Genus | Cryptopotamon (1) |
Classified as Vulnerable (VU) on the IUCN Red List (1).
Information on Cryptopotamon anacoluthon is currently being researched and written and will appear here shortly
This information is awaiting authentication by a species expert, and will be updated as soon as possible. If you are able to help please contact:
IUCN Red List (March, 2010)


text:
Source: FOOTYMAD
Toon Set To Waste Money On Turk?
Alan Pardew is STILL waiting to hear whether Mevlut Erding is ready to take on the challenge of leading the line at St James' Park next season. The Turk has already turned down Newcastle FOUR times, insisting he wants to stay in France . so why is Pardew so keen to sign a player who has no passion to play at St James' Park?Yet Alan Pardew is confident of landing a new striker in time for the opening clash with Arsenal.Erding has held talks with new PSG sporting director Leonardo and been told that he has ambitious plans to transform the French club's overall look.That means that Erding's future is in doubt and, with PSG already linked with Santos playmaker Ganso, who will cost 40m, the writing is on the wall for several of Leonardo's newly inherited squad.


text:
Spencers Mountain (1963)
Delmer Daves
Starring: Henry Fonda
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The big, warm-spirited forerunner to The Waltons.
Clayboy's schoolteacher impresses upon clayboy the following phrase, the world steps aside to let a man pass, if he knows where he is going |
Editor's Note
A clever take on life in Appalachia, SPENCER'S MOUNTAIN is a warm film. Its examination of the rustic frontier family, the Spencers, is sometimes funny, sometimes morose, but always striking. Henry Fonda stars as the macho head of the family, Clay Spencer, a dedicated worker, and an even more dedicated drinker. As Clay breaks his back putting food on the Spencer table, his wife Olivia (Maureen O'Hara) holds down the fort. Things seem promising for the Spencer family. Clay and Grandpa Spencer (Donald Crisp) are designing a new home and their oldest son Clayboy (James MacArthur) is planning to go off to college. However when Clayboy starts a romance with the daughter of his father's employer, Clay's job is put on the line and the Spencers suffer a family crisis.SPENCER'S MOUNTAIN is the feature film that inspired the hit TV series, THE WALTONS. As always, director Delmer Daves breathes life into his cast. Henry Fonda's performance of Clay--the drinking, crass, hard-headed head of the family--bears a slight resemblance to his character, Norman, in ON GOLDEN POND.
Cast & Crew
Donald Crisp | |
Henry Fonda | |
James MacArthur | |
Maureen O'Hara | |
Wally Cox | |
Earl Hamner - Based On Novel By | |
Charles Lawton - Cinematographer | |
Delmer Daves - Director | |
David Wages - Editor | |
Max Steiner - Musical Score | |
Delmer Daves - Producer | |
Delmer Daves - Writer |


text:
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text:
1 killed in crash on Highway 126
One person was killed this afternoon in a collision on Highway 126 near the eastern edge of Ventura County, authorities said.
The collision was reported at 2:08 p.m. just west of Newhall Ranch Road, according to the California Highway Patrol.
One person was killed and another suffered moderate to major injuries when one vehicle crossed into an opposing lane and struck an oncoming vehicle, said Sgt. Mike Moriarty of the California Highway Patrol's Moorpark office.
CHP investigators this afternoon are working to determine what caused the crash, Moriarty said.
One lane of the highway was closed in each direction as a result of the crash, Moriarty said.
At 3:40, he estimated the roadway could be completely open within an hour.
Subscribe to the Ventura County Star
Need Help? Call us at 1-877-710-6182.
Monday-Friday: 6am-3pm / Saturday: 6:30am-10:30am / Sunday: 7am-11am


text:
Teachers will find that our easy-to-use reproducible units align with and enhance concepts, themes, and skills found in sixth through twelfth grade state and national social science guidelines. Below we highlight the 14 Women in World History curriculum units we sell in our ONLINE STORE. We have included a detailed description of each unit (including the Table of Contents) and a Sample Activity from each unit that may be of use in the classroom. IF YOU PREFER TO ORDER VIA MAIL WITH A CHECK OR PURCHASE ORDER SPINDLE STORIES CURRICULUM UNITS - PRICE $10 each MIDDLE / HIGH SCHOOL CURRICULUM UNITS:
| Home Page | Lessons | Thematic Units | Biographies | Essays | Reviews: | Curriculum | Books | Historical Mysteries | | Q & A | ONLINE STORE | PDF FILE STORE | About Us | ©1996-2013 Women in World History Curriculum |


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THE BEST SEO PERSON on odesk PART 2
Closed - This job posting has been filled and work has been completed.
Job Description
We had an overwhelming amount of applicants for our first job post. We need a SEO expert for the following: ( PLEASE ONLY SERIOUS SEO experts need to apply***)
We need an SEO person to get us results for our client websites as fast as possible on Google Australia.
here are the requirements:
1. Great off and on page SEO Experience
2. Feedback score of 4.5
3. Portfolio needed
4. Optimize an average of 20 keywords for each client website
(we will send you what keyword to optimize for what page) we do most of the on page SEO.
5. Work per month for a fixed rate of $60 for 20 keywords
$30 for 10 keywords and $15 for 5 keywords
6. Each month we will assess the progress and if the clients are happy we will continue work with you. Great results are important
7. Optimize most for GOOGLE Australia
8. Use white hat SEO
9. Be available to speak to on Skype and email anytime
10. send us a report of your results
This is your chance to get a lot of ongoing monthly work. This is a great opportunity to be apart of. We have many websites to optimize.
We will hire 2 applicants to test and see who is the best for our needs.
Example website: http://www.logisticgo.com.au/
keyword: truck body
Please tell us how fast you can rank this website using the white SEO way.
Prove it to us and you will get the job.
Thank you
Skills: organic-search, off-page


text:
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Secret Ingredient Apple Pie
Rating: 5 Recommend: Y
Comments: The pie was delicious and enjoyed by all. However, the crust would not have won ...


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sorry for the lack of posts, however i would love to
announce some good news...you can now follow me on my journey as Fashion Editor
at ESSENCE.com! Hence the homage above of
vintage magazine covers.
I will now bring you more street style coverage, personal
chats with designers and hot fashion finds.
Follow me on this journey at ESSENCE.com/fashion and on
twitter @celiastyle
7 comments:
- IdreaminchanelDecember 17, 2011 at 11:12 PM
Major congrats! Just bookmarked your Essence page.
ReplyDelete In the words of Beyonce... "Thats a good look" Congratulations!!
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text:
Life Weaver
Credits & Info
- Date
- 04/01/2007
- File Info
- Song
- 2 min 50 sec
- Score
- 4.02 / 5.00
Related Content
You might also enjoy:
Licensing Terms
- Attribution:
- You must give credit to the artist.
- Noncommercial:
- You may not use this work for commercial purposes unless you make specific arrangements with the artist.
- Share Alike:
- If you alter, transform, or build upon this image, you may distribute the resulting creation only under a license identical to this one.
- Score:
- Rated 4.02 / 5 stars
- Plays & Downloads:
- 2,460 Plays | 372 Downloads
- Share Links:
- Genres:
- Easy Listening - Classical
- None
Author Comments
As my eyes gaze upon the love I have for my quilt of life, I listen to the melody it sings
Rated 4.5 / 5 stars
Love it but...
Not sure what to think about the drums. It was beautiful but I would have preferred something a bit lighter and less standard in the way of percussion, however that's my opinion so no need to change your style if that's how you want it.
Rated 5 / 5 stars
stunning...deserves more than JUST 5 stars....4.35/5.00 +(0.017) good luck bosa!
hope to be
.:bosa's number 1 fan:.
Rated 5 / 5 stars
I see this song as depicting a race. It starts out slow to represent the racers signing up for the race. Then it picks up to show maybe some of them greeting their friends who are going to watch them in the race. Then the racers line up. When the drums start up that means that they're off.
Rated 4 / 5 stars
Could use some work, but good
It is a very beautiful song that reflects a wide array of emotions. The chords seem to speak of sadness, yet hints of peace throughout. That is, until the drums come in. At that point, it takes on a more adventurous aspect, showing conflict and excitement while retaining some of that original sadness. The harp at the end was nice, but it ended too abruptly.
The piano was alright, but it felt very rough around the edges and synthetic. I would love some pedal in the bass and some more attention on dynamics. As always, I liked the strings. The drums were repetitive, but they served their perpuse I guess.
Work on dynamics, please add some pedal to the piano, give the drums some more variety, and you'll have a nice little piece under your belt. Can't say I understand how the title fits, but I dig the music. :)
5/5 vote, but 8/10 over all rating.
It's in my head, so it's completely not understandable.


text:
Systemwide Events Calendar
The Gift of Giving
November 5, 2012 - December 6, 2012Honolulu Campus, Cafeteria
Christmas Trees will be on display onstage at Boulevard Island Cafe. If you're interested in taking a tree home or decorating one with a group of friends or your student organization you must be an active student for the 2012 Fall semester. For more info about how to register to RECEIVE a tree CLICK HERE For more info on signing up to GIFT a tree CLICK HERE *Note: Gift of Giving is formerly our Adopt-A-Tree event.
Event Sponsor
Student Life & Development, Honolulu Campus
More Information
Tracy O. Alambatin, 845-9498, firstname.lastname@example.com
Tuesday, December 4 | |
7:30am | The Wellness Center - Fitness Class Schedule Maui Campus, Pilina Bldg., Wellness Center |
12:00pm | Linguistics Seminar Manoa Campus, St. John Auditiorium (St. John, Room 011) |
3:00pm | Physics Final Oral Manoa Campus, Watanabe 420 |
5:30pm | Part-Time/Evening JD Program Info Session Manoa Campus, William S. Richardson School of Law, Moot Court Room |
6:00pm | Japanese Flower Arranging - Ikebana Sogetsu Windward Campus, Hale Kuhina 115 |
6:30pm | Study with a Buddy! Hawai'i Campus, Manono Campus, Papa 'ā Hale (Building 380, Room 380-34B) |
- Highlighted dates have scheduled events.
- Select the date to view all events for that day.


text:
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greatlakes4x4.com is the premier Great Lakes 4x4 Forum on the internet. Registered Users do not see the above ads.
Thread Tools | Search this Thread |
May 2nd, 2012, 10:12 AM | #1 |
Senior Member
Misc jeep stuff
This is junk to me, but I figured I would see if there was any need for it before I scraped it or threw it in the trash. Unless otherwise listed $10/item + shipping, or make me an offer.
-Dana 30 diff cover (stock). A little rusty but solid and I have bolts for it too. -Ford 8.8 diff cover (stock). Excellent condition, includes bolts. -Ford 8.8 spider gears. Were set up but never run. -Jeep ABS sensors (front, x2). Came off of a ZJ but my guess it they'll fit other models. If you buy one you get both since I think one might be going bad but I don't know which. -Tensioner pulley/bracket off of a 96+ 4.0. Useful for someone with a pre 96 4.0 swapping in a 99+ intake -Dana 30 carrier, 3.55 & numerically lower, can include spiders if you need them -Front Wheel bearing for an SVT focus (Timken), NIB. -Jeep 4.0 throttle body from 98 ZJ. Can include IAC and TPS with it too. $40 |
Thread Tools | Search this Thread |


text:
Type: | Sport, 1 pitch, 45' |
Consensus: | YDS: 5.11- French: 6c Ewbanks: 22 UIAA: VIII+ ZA: 22 British: E3 5c [details] |
FA: | Mark Rolofson, Dave Turner |
Page Views: | 951 |
Submitted By: | Leo Paik on Oct 27, 2010 |
State Park; Fee Required. MORE INFO >>> |
Comments on Dude's Way | Add Comment |
Show which comments —
By Jay Eggleston From: Denver Aug 10, 2012 rating: 5.11a/b 6c 23 VIII- 23 E3 5c |
The start and crux are difficult if you are short. |
By TSluiter From: Monkton, VT Jun 7, 2013 |
The anchors are set back a little over a ledge. If you plan on TR, might want to bring long slings for your anchor to reduce the rub, though you'll lose the last mantle move to the top. |
By ChefMattThaner From: Lakewood, co Nov 9, 2013 rating: 5.11- 6c 22 VIII+ 22 E3 5c |
The eighth bolt is awkwardly placed and has the possibility to open the bottom gate on your draw if you are not careful. An extended draw will fix this. I also second the recommendation for extending the top anchors to reduce what otherwise is kinda rough rope drag. You will need the equivalent of 2 double length slings per each anchor since the anchors are so far back from the edge. |


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As "The Barefoot Foodie," Brittany Gibbons tried to be a famous food critic in the blogosphere, but that souffle never rose.
"It seems like I was always describing things as nutty or rich. I wasn't very good at it. And nobody read it," she said.
So the Swanton blogger veered into more familiar territory: "Brittany, Herself," a humorous journal of her life as a wife, a mother of three, and a plus-sized woman struggling with a lifetime of body issues. Regarding her posts as a cathartic journey of self-discovery and a platform for women's body advocacy, Gibbons had no idea her writing was striking a chord with scores of women experiencing similar feelings.
Seven years later, she has half a million monthly readers, national recognition, contracts with fashion companies to hawk their plus-size apparel, and a book deal with a publishing giant. And no one has found any of it more unexpected than Gibbons.
"I was living in a small town, and I had three small kids, and I really thought that this was going to be all for me. So this is an amazing twist. It's a surreal experience," she said.
"Fat Girl Walking," a humorous look at "a girl fumbling about, and trying to like herself" will be published by HarperCollins in early 2015. Gibbons, 33, will offer a preview of her wit and wisdom in a presentation at the Swanton Public Library on June 5 from 7-8 p.m.
Armed with a college degree in English and a hidden desire to "Saturday Night Live" and "Monty Python's Flying Circus," the Swanton High School graduate started blogging in 2007. When the food critic idea crashed –"I thought it was going to be brilliant, and it wasn't"–Gibbons began writing about topics she knew first-hand: marriage and motherhood.
"Other moms started reading me and relating to it," she said. "They finally had somebody who wasn't a Martha Stewart type telling them what they were doing wrong."
Three years ago, Gibbons started mentioning her 200-plus pounds, and her difficulty in accepting her body image.
"I wanted to get to a place where I loved my body. I started taking on women's body advocacy," she said.
That led to an invitation in 2011 to speak at the Technology, Entertainment, Design (TED) event at Bowling Green State University. Gibbons gave a sharp-humored speech about loving her body, then surprised the audience by stripping down to a bathing suit on stage.
She also became a spokesperson for plus size fashions by Lucky Jeans, ModCloth, and Lands' End, for whom she posed several times in swimwear in the heart of Times Square in New York City.
"It was terrifying, obviously. It felt a little bit like going down in an airplane,"she said dryly. "But I thought, 'It's happening, so live through it and go on.' The cause is just too great to not do it."
It was a life-changing experience, she added. "Nobody was really negative, which is also great. I've had a lot of women say thank you. It's turned into a huge community movement."
The experience inspired Gibbons to pose in bathing suits for her blog each spring; last year she took the dive and wore a bikini. The post went viral, and Gibbons was featured on "Good Morning America."
"'GMA' did a story on it – 'Girl in bathing suit' - breaking news!" she said with a laugh.
She is now working with an underwear company called Dear Kate. She did a photo shoot for them last month; the results will appear in the company catalog on its website.
Gibbons said readers should make no mistake about her posts being a "mommy" blog. She writes in a candid, blunt, and sometimes crude adult style about her life. Her frankness and honesty has been featured in a dozen magazines, notably "Women's Day" and "Ladie's Home Journal," which proclaimed her one of women who made the world happiest in 2013.
But what set the blogosphere and media buzzing was her post entitled, "I Had Sex Every Day For A Year." It was a funny take on how Gibbons' weight made her feel awkward in the bedroom, and how the experience changed her perception about her body.
The post went viral, and caught the attention of the "Today" show, which flew her to New York as a guest. Jay Leno also got into the act, taking a couple of comedic swipes at Gibbons on the "Tonight Show."
Shortly afterward, she was courted by four different publishing houses, which asked if she was ready to write a book. Gibbons tabled the idea, preferring the interaction of the Internet, but eventually struck a deal with a HarperCollins agent. The book wittily covers her life from childhood to the present, including her lifelong issues with weight.
"It's a daunting task," she admitted. "I'm used to writing a thousand words at a time, and now I'm telling my story in 3,000-word chapters."
She calls herself an accidental body advocate, but said, "So many women needed somebody to go up and do it for them. I get a lot of messages from women thanking me. I get a lot of emails from husbands thanking me for helping their wives. I've built sort of a 'girlfriend' brand just being myself."
Gibbons was prompted to become a women's body advocate, in part, after realizing how strongly her daughter resembled her.
"I thought, 'I hate myself, so obviously there's a problem here,'" she said. "I didn't want her to grow up feeling like I did. She loves fashion and dressing up, so I'm trying to build her up."
In the process of raising her daughter to have a positive self-image and sharing her feelings about body image on her blog, Gibbons said she healed herself. "I've gotten to a point where I appreciate my body so much. I just don't want to lose a pound. And women need to know that that's all right.
"We need to talk a little louder, and have women discuss that. It's so freeing…and it changes our lives."
Susan Bach, Swanton Public Library's adult services librarian, said Gibbons' story is one that will interest residents throughout the area.
"It's a really amazing story, and a happy one," Bach said. "There are so many different facets – the book, the blog, the body image work. This is amazing that someone could create such a great career working from home. The blog is very funny, and I think it's something that people would enjoy. And there's a huge intelligence there."
Gibbons said she has discussed with her husband Andy moving their family to the big city to further her career, but right now she prefers her small-town roots.
"I still wake up every morning in disbelief that this is my life," she said. "It's a surreal experience."


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Making noise in the blogosphere with beer.
Robb Larson has not received any gifts yet
UV contamination can happen during any step in the brewery to drinker chain. If you're at a grocery or liquor store and see green or clear bottles unprotected under florescent lighting then take your business elsewhere. If your buddy pulls up with a bunch of clear bottles in his sunny backseat…well maybe it just wasn't a bad batch. A good example to try at home is to pour an IPA or any light-hued, hop forward elixir in a clear pint glass on a sunny day then go out on the patio for a few…
ContinuePosted on May 8, 2013 at 10:22am
Three Irish Stouts are reviewed for St. Paddy's Day! Everyone have an awesome and safe holiday!
Comments are appreciated! Cheers!
Posted on March 16, 2012 at 9:21pm
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Safari 5 Released With Reader, Extensions
Apple Sneaks in Safari 5 Announcement After Keynote
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Coming as a free download on Mac (OS X Leopard 10.5.8 or Mac OS X Snow Leopard 10.6.2 or later) and Windows, Safari 5 will include Reader, which will allow you to browse news articles in an easy-to-read scrolling format, and will be opened up to developers to create extensions. Additionally, Bing will be made available in the search field, and the new update will reportedly boost performance by 30 percent over Safari 4. Strangely enough though, the links for downloading aren't live just yet, but you can wait for it to appear at www.apple.com/safari.
Update: The press release has been pulled by Apple. Stay tuned for another update!
Update 2: It's back! Download Safari 5 here.


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Heavy (pt 2)
Credits & Info
- Date
- 12/07/2008
- File Info
- Song
- 1 min 10 sec
- Score
- 3.06 / 5.00
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Heard in 3 Entries!
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View all submissions featuring this audio file.
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Licensing Terms
- Attribution:
- You must give credit to the artist.
- Noncommercial:
- You may not use this work for commercial purposes unless you make specific arrangements with the artist.
- Share Alike:
- If you alter, transform, or build upon this image, you may distribute the resulting creation only under a license identical to this one.
- Score:
- Rated 3.06 / 5 stars
- Plays & Downloads:
- 3,979 Plays | 429 Downloads
- Share Links:
- Genres:
- Metal, Rock - Heavy Metal
- None
Author Comments
An expansion of Heavy. Now with real bass =)
Good news, I got an early xmas present = Ibanez bass. I feel like my sound is finally becoming complete. This is the first time recording and mixing bass for my songs. It wasn't too hard, and is only going to sound better and better in the future.
Thanks to everyone who voted and reviewed my submission 'heavy', you guys rock. I'm going to be submitting to newgrounds for a while, so keep an ear out.
Me and TwilightNecrosis are working on a 9 song collab project called MetalForce, so watch out for that.
Anyway, I'll prob be writing some more songs soon. Maybe a little christmas present, we'll see.
thanks \m/
Rated 5 / 5 stars
YEAAAAAAAAAAH!!! \m/
I love the drums... And of course the bass. Both are ROCKIN. Great work dude!
Rated 5 / 5 stars
this song is nice and heavy (duh!) and heavy is the only awsome way
Rated 5 / 5 stars
Sorta reminds me of Shrine of the gods( my fave song by you) sux that you took it off but this song is still awesome keep up da good work
yeah, there will be more in the future.


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Discussions |
Academic Rigor |
Dorm Life |
Food and Dining |
Bang for the buck |
Clubs and Activities |
Campus Safety |
The Professors really push you to the hardest extent. They expect you to do your homework the first time and take school very seriously. However, if you finish your homework and work at it you will learn more than you expected and the way most professors teach the material it is guaranteed to stick.
To find more tips for prospective students, what to do for fun and whether this school is great for a particular type of student read the 80 reviews for Missouri University of Science and Technology
Curious about something that isn't answered here? Feel free to ask Missouri University of Science and Technology a question
Amazing school. Challenging and fun. Food sucks.
Read MoreNo regrets on choosing this school.
Read MoreMissouri University of Science and Technology is an exceptional school for serious and dedicated students. It is a very difficult school, but well worth the knowledge and experiences gained during enrollment. If you attend Science and Technology, you will have great opportunities to obtain internships, co-ops, and successful careers.
Read MoreThis school is one of the top engineering universities in the United States. They have many majors if you're interested in the STEM field, but only in that field. It is challenging and, at times, frustrating, but the rewards are fantastic.
Read MoreMissouri University of Science and Technology is one of my most recommended engineering colleges for those who want to become an engineer. There are lots of opportunities for students to get active in and the people there are great to get along with. Staff are there to help those who want to pursue their career and give good advice on what steps to take.
Read MoreMissouri S&T provides very high quality education. The neighborhood is very peaceful and appropriate for studying. The cost of attendance is very low compared to other institutions.
Read MoreThe campus is undergoing many changes, and the facilities are very nice. The students and faculty are always there to help and will make it very easy to find your place on campus.
Read MoreMissouri University of Science and Technology is a diverse campus full of students who want to be there and gain the best possible science based education. The professors make an effort to give you the one on one attention that is needed. S&T provides all the resources that are needed for you to succeed.
Read MoreI feel that this school has great learning programs and an amusing campus. Missouri University of Science and Technology is a great school to be at and they introduce you to many new people.
Read MoreIt's an amazing campus full of people willing to help you get where you want to go. There are many science and technology degree programs, but there are also some arts and business degree programs as well.
Read More


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You know you're way out west when you get your steak cooked on a pitchfork, served with all the fixings and you eat outdoors right in the middle of the North Dakota badlands while being serenaded with western melodies performed by cast members of the Medora Musical. That was one thick, juicy, delicious steak ... too bad I had no room for seconds.
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Sestriere, Italy
Sestriere Ski Holidays
Sestriere was the Alps first purpose built resort developed by Fiat's Giovanni Agnelli in the 1930's. The resort was built for snow so is high with North West facing slopes and has very extensive snowmaking. The village sits on a broad and sunny col and benefitted from recent investment at the 2006 Winter Olympics. It is very much an international resort that is part of the famous 'Milky Way' ski circuit so perfect for your ski holidays this year.
Sestriere Skiing and Snowboarding
As Sestriere is part of the famous 'Milky Way' it offers access to a stunning 400Km of pistes. Beginners will find the terrain to be good with several nursery areas and the gentlest of the easy blues down to Borgata. Intermediates will find plenty to amuse them in both of the sectors of Sestriere and confident intermediates will be able to explore practically all of the Milky Way areas. The runs in the Motta sector are more of a challenge. The huge bowl of the Amfiteatro offers excellent skiing and the black runs at the top of Motta and Sises give the experts plenty of skiing and boarding. There is a terrain park by the Garnel chair at Alpette. Cross country skiers will find three loops covering a total of 10Km
Sestriere Apres Ski
Apres ski in Sestriere is varied and becomes busier at the weekends when the Turin visitors come in. The Pinky is a bar and restaurant with low sofas and classic chic Italian style. Il Caminetto is also a lively place to be. Off the slopes there are some smart shops, a fitness centre and ice rink. There is also a sports centre and pool. It is also possible to visit the town of Pragelato.
Sestriere Childcare
Asilo Neve
Children from 2 years
Tel 00 39 0122 755 444
Sestriere Ski and Snowboard Hire
Pre book your ski and snowboard hire for your Sestriere ski holidays with Ski Set for online discounts
Sestriere Ski and Snowboard Schools
Scuola Nazional Sci Sestriere
Tel 0039 0122 77060
Email email@example.com
Website: http://www.scuolascisestriere.com
Scuola Sci Olimpionica Sestriere
Tel: 0039 0122 76116
Website: www.scuolasciolimpionica.it
Sestriere Webcam
Click on the Property Type to search for properties within Sestriere of that type.
Resort height: | 2000m |
Slopes: | 1390-2825m |
No. of lifts: | 38 |
Pistes: | 250Km |
Snow Canons: | 95Km |
Transfer Time: | 2hrs |
Off Piste: | ** |
Apres Ski: | *** |
Beginners: | *** |
Intermediates: | **** |
Advanced: | *** |


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What Does DogFriendly.com Offer? Select From Our Pull-Down Menu Dog-Friendly Hotels & Lodging Dog-Friendly City Guides ...Attractions, Restaurants & More Dog-Friendly Ski Resorts Dog-Friendly Camping/RV Parks Dog-Friendly Beach Guide Dog-Friendly Outdoor Dining Dog-Friendly Attraction Guide Dog-Friendly Park Guide Off-Leash Dog Parks Public Transportation & Dogs Dog Camps Dog-Friendly Events Dog Photo Gallery Dog & Pet Store Dog Travel Guide Books Top 10 Dog-Friendly Cities Top 10 Dog-Friendly Resorts DogFriendly.com's Newsletter Book Reseller Information Advertise with DogFriendly.com Online Press Kit About Us/Contact Us
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Sleep Inn & SuitesDog-Friendly Hotels2020 Franklin Terrace Ct.Johnson City,Tennessee 37604Call 866-676-3077 To Book This Hotel Get Map or Directions FREE HIGH SPEED WIRELESS INTERNET ACCESS, microwaves, and refrigerators in all rooms! Convenient to major shopping, restaurants, MED TECH Business Park, Johnson City Medical Center, and ETSU. Visible from the interstate. Pet charge: 10.00 per night, per pet, up to 25 lbs. Pet limit: 2 pets per room.Convenient to major shopping, restaurants, business parks, medical cntrs, and ETSU. Visible from Interstate. Dogs up to 25 pounds are allowed. Dogs are allowed for a pet fee of $10.00 per pet per night. Two dogs are allowed per room.
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We are thrilled to announce that Hetalia: The Beautiful World will begin streaming on our site today at 2pm CT (3pm ET)! Pretty exciting, right?
The Allied guys and Axis boys are back in Hetalia: The Beautiful World! It's Season 5. As in high-five! And when we high-five, a tiny kitten appears with a wee banjo! And he's playing a song about a cupcake and it's freaking adorable! But then Prussia shows up and yells at the kitten. But the kitten doesn't get sad, because, dude… Claaaassic Prussia.
While we're at it, let's go over the entire simulcast schedule for this winter season.
Kingdom | Mon | 11:00am ET | |
Senran Kagura | Mon | 11:30am ET | |
PUCHIM@S | Mon-Fri | 12pm ET | |
Haganai NEXT | Tues | 11am ET | |
Toriko | Weds | _ | |
Psycho-Pass | Thurs | 11:45am ET | |
Minami-ke: Tadaima |
Fri | 11:30am ET | |
Robotics;Notes | Fri | 12:15pm ET | |
Hetalia: The Beautiful World |
Fri | 3pm ET | |
One Piece | Sat | 9pm ET |
Don't forget to also tune in for our noitaminA nights Live Stream on Friday nights at 7pm ET/6pm CT as we watch and live chat about the latest episodes of Psycho-Pass and Robotics;Notes. Just subscribe to our new Live Stream channel on YouTube at http://youtube.com/FUNimationLiveto stay up to date on these kinds of events. Listen for the secret password each week for a chance to win some fabulous prizes!


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Accident in Chicago, Illinois
March 28, 2006 - In the mid-morning hours, Chicago firefighters responded to the outbound (southbound) Dan Ryan Expressway (near U.S. Cellular Field) for a traffic accident. The influx of calls and information recieved prompted fire alarm operators to send extra fire equipment. A small passenger car had rear ended an 18 wheeler. A dump truck behind the passenger vehicle could not stop in time.
As a result the passenger vehicle was smashed like an accordion trapping the driver. Firefighters from eng co.29, truck co.11, the 2nd battalion, and the members of the Illinois Department of Transportation were successful in extricating the victim. Ambulance 1 transported the victim to the hospital.
The Dan Ryan Expressway is scheduled for a massive construction project starting in april that will last for three years.


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Seminar Series
Environmentally Sustainable Business Practices
This spring the Institute of Environmental Sustainability and Quinlan School of Business are presenting a series of three seminars on Environmentally Sustainable Business Practices. Join us to learn about successful collaborations between environmental sustainability and business management, and bring your questions!
Monday April 08 11 –12 |
Andrew Hoffman, Ph.D. | Holcim (US) Professor of Sustainable Enterprise University of Michigan |
LSC Cudahy Science 313 |
Friday April 12 11 – 12 |
Dan McGowan | President, Big Bowl, Big Bowl Chinese Express L. Woods Tap and Pine Lodge |
LSC IC fourth floor |
Monday April 22 1 - 2 |
David Saiia, Ph.D. | Associate Professor Strategic Management & Sustainability Duquesne University |
WTC Beane Hall |


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Hunting for the Governor
South Carolina state troopers didn't know where Sanford was during his absence and couldn't find out from staff, the Washington Post reports. The ...
South Carolina state troopers didn't know where Sanford was during his absence and couldn't find out from staff, the Washington Post reports.
The security detail for South Carolina Gov. Mark Sanford was actively searching for him over the weekend and concerned about his safety, but getting the runaround from his staff in trying to contact him, the director of the state's law enforcement agency said in an interview this afternoon.
Sanford asked his protective detail to "stand down" at 1 p.m. last Thursday at his mansion, and then drove off alone in a state law enforcement sport-utility vehicle, the director said. But agents weren't concerned until they heard a rumor Saturday that the governor had been spotted speeding on a South Carolina interstate in an SUV.
"At some point during the course of all of this, we were able to talk to his chief of staff. He passed along the fact that the governor was okay. They said they were attempting to reach him about this story, they knew where he was, he was okay," [state Law Enforcement Division chief Reggie] Lloyd [pictured with Sanford above] said.
It wasn't unusual for Sanford to ask for his security detail to leave him alone for a few days, Lloyd said.
"As an adult male, he's free to come and go as he pleases," said Lloyd. "There were times when he would want to get away. He's been in office 6 1/2 years. He very much values his time away from the office. It had become routine enough that it was not suspicious."
The New York Times has a piece rounding up the history of other politicians who have liked to go missing for a few days, including Mayor Michael Bloomberg and Govs. Arnold Schwarzenegger and Jon Corzine.
It just occurred to me that when I was in Topeka a few years ago reporting a story, someone on Kathleen Sebelius' staff let slip that she was down in New Orleans for the weekend but that I shouldn't tell anyone. I guess it doesn't matter now. But if politicians like to slip away without alerting the press or much of the state government, by necessity that means this sort of thing must happen more often than we think.
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Our new devotional "If God Loves Me, Why Did I Lose My Job?" explores the struggle of unemployment. Sign up here.
A state of lack of knowledge or information, including a failure to know the person, will and ways of God. Scripture emphasises the importance of a true knowledge of God and makes such knowledge available.


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See Details
-Buenos Aires
-Alter Do Chão (Amazon River)
-Manaus (Amazon River)
-Rio de Janeiro
-Lima (Callao)
Valparaíso is the principal port and second largest city of Chile. The city is situated on the shores of a sweeping bay and on a crescent of hills behind. Seen from the ocean, it presents a majestic panorama; a great circle of hills is backed by the snow-capped peaks of the distant Cordillera. Due to Valparaiso's convenient location along the shipping routes circling Cape Horn, the port experienced a tremendous boost when the ports and the Americas were opened to world trade.
View Cruises that visit this port
Grand Hyatt Santiago hotel is a 5 star luxury hotel in the exclusive business district of Las Condes in Santiago, Chile. Our hotel in Santiago offers easy access to Santiago city centre and Santiago de Chile's international and domestic airports.
Grand Hyatt Santiago hotel is also home to world-class, multi-cuisine restaurants, a lagoon-style swimming pool with a waterfall, a tennis court, and the three-story free-standing AKO Wellness & Spa. The most exclusive golf clubs of Santiago de Chile are only a few steps away from the hotel. Our Las Condes hotel also features a health club where guests can pamper with a variety of beauty and relaxation treatments.
Check-in Time: 10am
Check-out Time: 6pm
Hotel and Land Program pricing is not combinable with FREE 1-Night Pre-Cruise Luxury Hotel Package. If applicable, please contact Regent Seven Seas Cruises or your travel agent for multi-night pre-cruise hotel pricing information. Land program promotions are subject to terms.


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Caption: Brandon Marshall Wearing His Wifes Face on his Shirt (Photo)
by BSO Staff | Posted on Wednesday, July 17th, 2013
Sometimes, people just have different relationships than what you and I might consider normal. Brandon Marshall and Michelle Nogami certainly fit that bill. There was the alleged stabbing several years back and the time she got hit in the head with a bottle at the club sparking a huge brawl.
Things have apparently calmed down in the Marshall household, and last night they were spotted together at an ESPY party. Interesting to note, not only Marshall with his lady, he is wearing her image on his shirt.
This Marshall picture should work better. pic.twitter.com/Xy3GEAdm1j
— jon greenberg (@espnchijon) July 17, 2013
That's some straight Doug Christie stuff right there.
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Type: Task
Status: Closed
Priority: Minor
Resolution: Fixed
Component/s: moodle.org
Martin - I'm beginning to wonder if modules like feedback and questionnaire that are not part of Moodle core should be placed under a special section to make clear that these are 3rd party contributions. I think the greater clarity we can provide the better.
As I've been working on the CONTRIB stuff I've been wondering if we would be better having it separated out a little.
Another question has to do with access. If we create a CONTRIB section in the Using Moodle course, would it be better to have Helen create a new forum for new contributions (modules, blocks, etc.) or easier to give me access to create them. In particular, I'm thinking of the tracker module that has recently been added. I think having separate forums for these in a designated section of the course would facilitate communication. As much as possible I would like to see that we have consistency and a forum for each block and module.
Peace - Anthony
Gliffy Diagrams
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MDL-12622 Enable forum discussions to be moved to a forum in a different course
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Acute Kidney Failure (cont.) IN THIS ARTICLE
Acute Kidney Failure Symptoms
Patient Comments
Read 5 Comments
The following symptoms may occur with acute kidney failure. Some people have no symptoms, at least in the early stages. The symptoms may be very subtle.
Seizures and coma may occur in very severe acute kidney failure. Medically Reviewed by a Doctor on 11/10/2014
Medical Author:
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Acute Renal Failure »
Acute renal failure (ARF) or acute kidney injury (AKI), as it is now referred to in the literature, is defined as an abrupt or rapid decline in renal filtration function.


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Local Veterinarians in Your Area
1. Banfield Pet Hospital® - El Paso Zaragoza
1836 Joe Battle Blvd, El Paso, TX 79936
A great local veterinarian loves your pet (almost) as much as you do by providing the best preventive pet health care. From nose-to-tail veterinary medical exams to vaccinations, microchipping, dental care and surgery, you'll find the vet your pet deserves at your neighborhood Banfield Pet
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Services: Animal Flea Control, Animal Microchipping, Small Animal Vet, Spaying/Neutering, Veterinarians, Veterinary Dentistry, Veterinary Euthanasia, Veterinary Surgery, Veterinary Vaccinations
Free Exam & Consultation - This coupon is good for one office visit and general physical exam. No purchase required. Fees will apply for additional services that customer requests, including diagnostic tests, medications, treatment, and hospitalization. Cannot be applied toward wellness plan membership fee or any other charges. Not valid with any other offers. One coupon per person for new clients only and first pet only. Valid for dogs and cats at participating locations in the U.S. No cash value. Void where prohibited by law. Free Office Visit PW#5597.